MyMedicare Registration Form

Family name *

First given name *

Second given name

Medicare number or DVA File Number *

Medicare IRN (number next to your name) *

Practice Name and Address

Ascot Vale Health Group, 73 Union road, Ascot Vale Vic 3032

Name of Preferred GP *

Full Name of individual providing consent

First Name

Last Name

Consent - I agree

Date

Consent for patients aged between 14-17 years of age

I Consent

(once you select submit the Practice will register you for MyMedicare)

Enquiry

* Required fields